1 The first article, “Nurses’ and Doctors’ Knowledge of Pain after Surgery” aims to analyze the links between levels of acute pain management knowledge, perceptions of clinical skills, and the acute pain management education history of doctors and nurses working in orthopedics and general surgery in an acute hospital. This aim of the research is clearly stated in the study. An abstract was also given at the beginning of the study.
Various literature have already emphasized that despite the ideals of professionalism, education and the establishment of acute pain management, some health care practitioners still lack knowledge of pain management and have misconceptions of pain behaviors and pain relief methods, which are not conducive to high-quality care. It must be noted that pain is the most common symptom for which patients seeks help and can reflect either physical or emotional discomfort (The Merck Manual, 1999). Knowledge of pain assessment and management is therefore vital.
To gather data, the researchers structured a questionnaire that was designed to identify professional demographics and educational input, barriers to acute pain management, perceived competence in clinical skills and to test knowledge using an abridged version of a validated questionnaire which was annotated to trust standards.
A convenience sample was taken from one of the three acute hospitals in the trust. It consisted of 101 permanent, trained doctors and nurses from three orthopaedic and two surgical wards. The sample was purposefully selected to coincide with the end of the junior doctors' six-month appointments, when they should have had greatest knowledge of the trust's standards.
An ethics approval to perform the study was not sought since the researchers reasoned out that there were no vulnerable subjects. However, a proposal outlining the study's method of enquiry was registered and scrutinised for scientific worthiness by the trust's research and development department through a process of peer review and supervision.
Questionnaires were distributed by hand in sealed envelopes with guidelines on the purpose and objectives of the study. Participant anonymity was assured. In an attempt to reduce bias the respondents were requested not to disclose, discuss or reproduce the questions with anyone else to ensure that the respondents' answers were not influenced by others.
The results identified the most useful sources of acute pain management education and who accessed these; barriers to good acute pain management, other than a lack of education; differences between doctors and nurses in standards of education, levels of perceived competence and knowledge in assessment, pharmacology and analgesic delivery systems.
The evaluation of pain is one of the many physician (Bickley & Szilagyi, 2003) and nursing responsibilities that require effective critical thinking (Potter & Perry, 2004). The patient’s behavioral response to pain relief management and interventions is not always obvious, thus the physicians and nurses must be knowledgeable in observing and knowing patient responses to pain relief interventions and management.
2 The second article is “Nurses’ Knowledge, Attitudes, and Practices: Regarding Children’s Pain” by Catherine Van Hulle Vincent. It aims to describe the knowledge and attitudes of nurses about relieving children’s pain, perceived barriers to optimal pain management, and analgesics administered by nurses in relation to levels of children’s pain. Management of pain is a prime consideration for many health care professionals (The Merck Manual, 1999).
The data used in the study is collected from 67 nurses and 132 children in their care. This is appropriate since from the sample mentioned in the study, the population comprised of children with different racial identities and different sexes. The age of these children ranges from 3.5 to 17 years, experiencing pain of variety. The sample could therefore be considered as a representative of a whole. An approval was obtained from the Behavioral Institutional Review Board at the participating agency. Nurses were recruited and consent was obtained, children who were patients cared for by the sample nurses were recruited, and parental consent for their child to participate and child assent were obtained.
The nurses’ knowledge and attitudes were measured with a 33-item instrument derived from the 37-item Nurses’ Knowledge and Attitudes Survey Regarding Pain. This instrument was used with permission from the original developer. As this instrument has already been used, it is likely that the results from the answers of the nurses would be valid. On the part of the children levels of pain were measured on a scale of 0 to 5 using six photographic scales of the Oucher. The photographs of a child’s face on each vertical scale represent increasing levels of pain. It must be noted that this is more of an observation on the part of the one observing the faces of the children.
Misinterpretation could likely occur. The nurse must therefore be aware of possible errors in pain assessment. Using the right tools and methods can help to avoid errors and to ensure that the right pain interventions are chosen. Failure of clinicians to assess a patient’s pain, accept the findings, and treat the report of pain is a common cause of unrelieved pain and suffering (Kozier & Erb, 2004).
The results of the study show that most nurses demonstrated knowledge and positive attitudes about relieving children’s pain but lacked knowledge about the incidence of respiratory depression and thought that children over-repot pain. Inadequate or insufficient physician medication orders for pain were identified by 99% of nurses as the greatest barrier to optimal pain management. Of the 117 children who reported pain, 74% received analgesia. Nurses administered means of 37.9% of available morphine and 22.8% of available total analgesia.
Several pain assessment tools have been developed for children, but these tools have not been consistently used in practice. Similarly, pharmacological and nonpharmacological advances in the management of pain have been documented to be effective, but their use in practice has not been maximized (Puntillo, 1999), as could be seen in the study.
The use of analgesics is the most common method of pain relief. The nurses using this in the study could significantly affect the children’s perception of pain. Although analgesics can effectively relieve pain, nurses and physicians still tend to undertreat the patients because of incorrect drug information, concerns about addiction, anxiety over errors in using opioid analgesics, and administration of less medication than was ordered (Potter & Perry, 2004). Nurses in practice therefore need to become more aware of the adequacy of their analgesic administration, the value of children’s self-report of pain, and the limitations of relying on children’s behavioral manifestations to judge pain intensity. It is therefore necessary for nurses to understand the drugs available for pain relief and their pharmacological effects on the children. This study also demonstrates the importance of examining attitudes about children’s pain relief and learning more about respiratory depression in children receiving.
3 The third article is “Influences of Patient Behavior on Clinical Nurses’ Pain Assessment: Implication for Continuing Education” by Horbury, Henderson, and Bromley. This study was realized as a result of poor attendance by nurses at inservice sessions discussing pain assessment and management.
The aim of this investigation was to study nurses' intention to treat pain in different patients. The study participants were registered nurses working in the inpatient areas of the Divisions of Surgery, Medicine, and Oncology, including critical care areas in a tertiary Australian teaching hospital. All nurses on the roster for each ward area during 1 calendar month were targeted. Consent was obtained from the Nursing Directors of the participating areas together with ethics approval from the Nursing Research Committee at the hospital.
A 10-page questionnaire with eight different patient scenarios was distributed to 886 nurses across all clinical divisions of an acute tertiary facility. A questionnaire, comprising eight vignettes was used. Each vignette described a hypothetical situation and asked the respondents to select a dosage of pain relief medication they would administer.
Data were analyzed using descriptive statistics. It was an expectation that further analysis could be undertaken between the different groups within the hospital. However, given the low response rate, there were not significant numbers representative of any specific group to make reliable comparisons. Results indicate knowledge deficits regarding optimum pain relief for patients. These findings support existing literature that nurses do not necessarily accept patients' self-report of pain. They suggest nurses are influenced by patients' age and behavior when rating pain. Nurses were more comfortable accepting the self-report from elderly patients, particularly with a grimacing expression, than from the younger group. However, they were reluctant to administer appropriate levels of analgesia due to fear of respiratory depression. These trends were also consistent with the literature. But nurses must remember that respiratory depression is only clinically significant if there is a decrease in the rate and depth of respirations from the patient’s baseline assessment (Potter & Perry, 2004).
The study also mentioned its limitations, that being the sample not a representative of the whole population. But despite that, the findings suggest that a more active role in the provision of education about pain assessment and management to nursing staff is required. This article highlights the need for innovative teaching strategies and approaches in the clinical context to heighten nurses' awareness of their lack of knowledge of pain assessment and management.
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